tDCS

Transcranial direct current stimulation
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Transcranial direct current stimulation has been determined safe for human use due to the low current used and can result in cortical modulations that last longer than the time of stimulation. Currently, tDCS is used as therapy for certain psychological disorders such as anxiety disorders and depression, as well as a tool for motor rehabilitation instroke patients.

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info

Anodal + Cathodal The anodal stimulation is positive stimulation that increases the neuronal excitability of the area being stimulated. Cathodal stimulation decreases the neuronal excitability of the area being stimulated. An example of how cathodal stimulation could be used is as a therapy for a psychological disorder caused by the hyper-activity of a particular area of the brain. Cathodal stimulation would decrease the neuronal excitability to reach a more stable level of activity. When positive stimulation is delivered, the current causes a depolarization of the resting membrane potential, which increases neuronal excitability and allows for more spontaneous cell firing. When negative stimulation is delivered, the current causes a hyperpolarization of the resting membrane potential. This decreases neuron excitability due to the decreased spontaneous cell firing.

Safety
When applied following established safety protocols, transcranial direct current stimulation is widely regarded as a safe method of brain stimulation, causing no apparent short-term harm. Safety protocols limit the current, duration, and frequency of stimulation, thereby limiting the effects and risk

Safety protocol
Studies have been completed to determine the current density at which overt brain damage occurs in rats. It was found that in cathodal stimulation, a current density of 142.9 A/m2 delivering a charge density of 52400 C/m2 or higher caused a brain lesion in the rat. This is over two orders of magnitude from what is currently being used. (14,2mA cm2 ) There is currently no evidence of serious side-effects after tDCS in humans. Common side effects include mild headache and itching sensation at the electrode site. Skin lesions (burns) have been reported after tDCS and considerable care is needed in examining and preparing the skin-electrode interface. There are no reports of tDCS inducing seizure. In the literature it is strongly recommended not to exceed the threshold of 0.05 mA/cm2 that could cause a painful sensation and tissue damages. In this way, the stimulation is far from this threshold for tissue damage (14.3 mA/cm2) recently indicated for tDCS in an animal model. It is mandatory to read and understand the scientific literature relative to transcranial and trans-spinal DC stimulation before prescribing any treatment. In the next figure, intensity values (in mA) and electrode area values (cm2) for a current density of 0.02 mA/cm2 (dark orange) and of 0.05 mA/cm2 (light orange) are drawn. It is recommended to use intensity/area pairs positioned in the area between the two lines. Below the light orange line there is a danger zone.

A phosphene is a brief flash of light and this effect can occur if an electrode is placed near to the eye. dizziness.029 and 0. a phosphene at the start of stimulation. *Adverse effects A structural and diffusion-weighted magnetic resonance imaging study [28] compared the prefrontal cortex before and after anodal and cathodal tDCS. Also.There is no strict limitation on the duration of stimulation set at this point but a stimulation time of 20 minutes is considered the ideal time. update: The current density produced by present tDCS protocols ranges between 0. and itching under the electrode.[6] There are several ways to reduce the skin irritation felt during stimulation. which are used for stimulation of the vestibular system (GVS). A stimulation length of 10 minutes results in observed effects lasting for up to an hour. Also. These side effects include skin irritation. The longer the stimulation duration.[2] A recent study of over 500 subjects using the currently accepted protocol reported only a slight skin irritation (increase of blodd flow)and a phosphene as side effects. it is advised to warn the person receiving the stimulation of the possible after effects of the tDCS stimulation. This is done by slowly increasing the current until the desired current is reached.08 mA/cm2 Side effects of stimulation There are a few minor side effects that can be felt by the person while receiving the stimulation. Nausea most commonly occurs when the electrodes are placed above the mastoid. ramping up the current can reduce the irritation. One of the most important methods of preventing skin irritation is by preparing the electrodes with saline solution and the skin with electrode cream thoroughly.headache. and found no structural alterations or disturbances of the blood-brain barrier. nausea. It is generally encouraged to wait at least 48 hours to a week before repeating the stimulation. the longer the observed effects of the stimulation persist once the stimulation has ended. and most of these can be controlled by correct set up of the device. and no reduction in apparent diffusion coefficient values (a .

spontaneous neuronal firing in vivo in animal studies. coupled with synaptic neuroplasticity. Non-synaptic mechanisms: There is evidence that anodal stimulation shifts neuronal resting membrane potential towards depolarisation. The effect of tDCS on motor cortex excitability can be measured by motor evoked potentials (MEP) recorded from peripheral muscles. protein synthesis during stimulation. Several studies demonstrated that anodal direct currents increase. As more is discovered about the use of tDCS. but since this technique of stimulation is still being explored. tDCS to the visual cortex produces changes in visual evoked potentials. polarizing currents applied to the brain surface can change cortical evoked potentials and the activity of individual neurons. conversely. *Imaging modalities. *In isolated preparations. Other studies have reported no significant changes in levels of neuron-specific enolase (a sensitive marker of neuronal damage) immediately or 1 hour after tDCS Risks There are no known risks of tDCS at this time.1 The effect has a preference for fields oriented along the axo-dendritic axis.23] have suggested changes in regional blood flow. These include correlations between neuronal activity patterns known to underlie LTP/LTD. * epilepsy tdcs study MECHANISMS OF ACTION A leading view is that changes in spontaneous neuronal firing rates. while cathodal stimulation causes hyperpolarisation. 5–40 s) causes neuronal depolarisation.and long-term effects of anodic stimulation. making it important to remain familiar with the most currently updated safety protocol. it is not advised to administer this stimulation to people susceptible to seizures. Similarly. while cathodal direct currents decrease. glutamatergic neurotransmission and membrane function after tDCS. contribute to intra. the safety standards may change. Anodal tDCS could induce long-term potentiation (LTP) through increased pre-synaptic activity coupled with postsynaptic depolarisation. the changes were shown to be long-lasting: 5 to 10 min of continuous stimulation produced effects up to 5 hours afterwards.and post-stimulation effects respectively. Intracellular recordings from animal studies have shown that anodal stimulation (30–400 μA/mm2. The set protocols must be followed in ensure correct use of the device. Anodal tDCS to the motor cortex (0. such as people with epilepsy. In mammals. and especially the emerging role of NMDA receptors in regulating the aftereffects of stimulation. Although seizures do not seem to be a risk for healthy individuals. Human motor cortex studies provide further evidence of these non-synaptic mechanisms. whereas glutamate channels blockers have eliminated only the long-term effects. The evidence for a neuroplastic synaptic contribution to the effects of tDCS is thus compelling. those with a tendency towards seizures may[ react differently. Moreover. contrast sensitivity and motion detection threshold. *post-TDCS effects could be explained by the modulation of the activity of N-methyl-D-aspartic acid (NMDA) receptors.Also. cathodal tDCS could induce long-term depression (LTD) through reduced presynaptic discharge and postsynaptic hyperpolarisation.marker of cytotoxic oedema). while cathodal tDCS reduces MEP size. including in brain regions distal to the site of stimulation. while cathodal stimulation shifts resting membrane potential towards hyperpolarisation. * calcium and sodium channel blockers have eliminated the short. *The effects of cortical inhibition suggest that TDCS modulates the excitability of both the inhibitory interneurons and excitatory neurons.2–5 mA. also in a direction that is dependent on the polarity of stimulation. safety precautions should be kept. including positron emission tomography . Synaptic mechanisms: tDCS induces changes by altering the strength of synaptic transmission. 4 s–5 min) increases MEP size. Spontaneous neuronal firing: tDCS directly induces neuronal firing.there is empirical evidence from animal studies that even small voltage gradients of this magnitude can change the firing rate of neurons. and those patterns observed after tDCS. functional magnetic resonance imaging [21] and magnetic resonance spectroscopy [22.2-4 . nondestructive DC currents can change the firing rate of spontaneouslyactive neurons by up to 72%.

5 weeks. after 10 consecutive weekdays of treatment [7].5%. two double-blinded.*D2 receptors play a major supporting role in inducing neuroplasticity in the human motor cortex. Transcranial direct current stimulation as treatment .[10] Stimulation therapy could also be developed into effective therapy for various psychological disorders such as depression. fibromyalgia. Another trial also reported positive findings. anxiety disorders.4% in the sham group. but more rapid onset. Psychological The majority of psychological studies involving tDCS focus on the expansion of knowledge about a certain region of the brain or a certain psychological phenomenon. The readiest explanation for this pattern of results is that D2 receptor activation has a consolidation-enhancing effect on tDCS-induced changes of excitability in the human cortex. Using these newer techniques. For example. [8] tinnitus. stroke patients with speech difficulties displayed great improvement through a tDCS based therapy. -effect on peripheral nervous system Uses Clinical Clinical therapy using tDCS may be the most promising application of this technique. and schizophrenia. One trial reported 69% improvement in mean Hamilton Depression Rating Scale (HDRS) scores after five sessions of active tDCS over 1.7]. sham-controlled studies using left prefrontal tDCS (1 and 2 mA. compared with 30% improvement in the sham group [6]. compared to a 6-week course of 20 mg/day fluoxetine. much work is done on the ability and specifics of working memory. with improvement in the active group on HDRS of 40.[11] Many of these studies stimulate a particular region of the brain and then observe the effects of the stimulation in some type of cognitive task. compared to 10. D1 receptors by pergolide consolidated tDCS-generated excitability diminution until the morning after stimulation.[9] In a recent study. Moreover. a . these differences in outcome between active and sham groups persisted at 1-month follow-up. could arise from alterations in transmembrane proteins and from electrolysis-related changes in [H+] induced by exposure to constant electric field. These changes apart from reflecting local changes in ionic concentrations. with the improvement lasting past the one week retest. and an open-label extension of the trial indicated that tDCS had similar efficacy. *importance of D2 receptor activity for the induction of increases and decreases in prolonged NMDA receptor-dependent motor cortical excitability shifts *Non-synaptic mechanisms underlie the after-effects of cathodal transcutaneous direct current stimulation of the human brain -Ourfindings demonstrate that the after-effects of tDCS have a non-synaptic mechanism of action based upon changes in neural membrane function. and post-stroke motor deficits. Enhancement of D2 and. to a lesser degree. 20 minutes per day for up to 10 days) reported positive results in reducing depressive symptoms [6. There have been therapeutic effects shown in clinical trials involving Parkinson’s disease.

Fregni and his group at Harvard advocate using a shoulder for the reference placement. referred for electroconvulsive therapy. non-placebo controlled clinical trial involving hospitalised patients with drug-resistant depression at high risk of suicide. whereas the circuit-completing inactive electrode is called the reference electrode. modern tDCS techniques have failed to replicate the dramatic findings of older clinical trials on mood in healthy subjects. the studies never looked at the inhibiting effects that the reference electrode might have had on the prefrontal lobe. reported >30% improvement in depression rating scores [HDRS and BDI (Beck Depression Inventory)] after anodal stimulation to the left dorsolateral prefrontal cortex (2 mA.54 cm in one inch. A more recent. double-blinded. On the other hand. There is also some evidence that tDCS may be effective in improving functional recovery after stroke. Interestingly. 10 minutes) to the left frontotemporal region significantly improved performance on a picture-naming task in poststroke patients with chronic aphasia immediately after stimulation [13]. 15-60 minutes) increased the threshold for localised seizure activity. No significant effects on emotional state. Similar to the depression trial. arousal and psychomotor function were found. The clinical evidence for tDCS treatment of epilepsy in humans. where the active electrode (anode) is placed over the dorsolateral prefrontal cortex (F3 on the 10-20 electrode montage) and the cathode over F4.54 cm = 6. The negative electrode is called the cathode and it reduces brain function under the electrode site by 10 to 30% at the fore-mentioned current density. therefore a 1” square electrode is 2. A randomised. the analgesic effect appeared to be cumulative. with greatest overall pain reduction after five sessions of treatment. However. (2007) show that it is better to have a small stimulating electrode and large reference electrode. Some recent studies and in particular a study by Nitsche. Brain function under the electrode site is enhanced by roughly 20 to 40% when the current density (concentration of amperage under the electrode) exceeds 40 µa/cm2 (260 µa/inch2). however. it is uncertain if administering tDCS twice per day was more efficacious than once-daily treatment. The same parameters have also been reported to alleviate pain in fibromyalgia [12]. for 5 days) [9]. remains limited (see [15] for a review). et al. emotional decision-making.selective serotonin re-uptake inhibitor antidepressant [8].54 cm x 2. In most of the studies. 20 minutes. the current density is high under the treatment electrode and weak under the reference electrode. five sessions) has also demonstrated the efficacy of tDCS for the treatment of chronic pain due to spinal cord injury [11]. In a double-blind crossover trial. An animal study in rats demonstrated that cathodal tDCS (100-200 µA. This arrangement allows the reference electrode to be placed most anywhere over the scalp without it affecting brain function beneath it.45 cm2). differences in pain scores between the active and sham group were still present at 2-week follow-up.. *current direction A recent sham-controlled trial with anodal stimulation to the primary motor cortex (2 mA. Most studies have used stimulation at 1 mA of current through 7cm x 7cm (49 cm2 ) electrodes *update 15-25-35cm2 (There are 2. TECHNICAL ASPECTS OF tDCS: The positive electrode is called the anode. the reference has been placed over the contralateral orbit (above the left or right eye) to avoid negative effects from it. suggesting a potential therapeutic role in epilepsy [14]. As this was an uncontrolled study. The brain-stimulating electrode is called the active electrode. affect. This way. I also advocate using a shoulder placement except possibly for treating depression. Anodal stimulation is the most common form of tDCS as it enhances brain function. sham-controlled trial found that cathodal tDCS (2 mA. twice-daily. 21 subjects received bilateral frontal tDCS with an extracephalic reference electrode [10]. .

If the reference cathode was also used on the head instead of the shoulder. then the device should automatically increase the voltage to 20 volts in order to push the 1 ma current through the body. the increase in the . if the resistance of the skin is 10. If for some reason.2 ma when pressure was applied to the shoulder electrode. By applying a mild pressure on the arm electrode. there would have been a significant inhibition effect around it. et al.*current direction to nerons orientations Nitsche and Paulus found that a minimum current density of 17 µa/cm2 was needed to excite motor neurons. For instance. Boggio.1 cm) wet sponge cathode on the left arm and found that at the onset. We then soaked the electrodes (1 ¾”x 1 ¾”and 2”x 4”) in a 5% salt solution. The current was a whopping 3 ma. tDCS DEVICES . It is important that the tDCS device is current controlled. The CESta has been “tuned” with the electrodes provided so that at 1 ma stimulation. The currents in both situations are well below the necessary value of 40 ua / cm2.000 ohms. then 10 volts will be needed to “push” 1 ma through the body. the current rose to 0.. What this means is that the device will adjust the voltage up and down as the resistance changes sot that the current never changes. In this case. (current density of 150 ua/cm2) as confirmed by the ammeter and the stinging on my forehead. Studies involving other regions of the brain have suggested that 20 to 25 µa/cm2 are needed to excite neurons under the electrode. The variance was also 2 to 1.. the current density was much too high. but significant improvements at 2 mA (current density of 20 µa/cm2 vs 41 µa/cm2). 2007.5 x 4. observed that when stimulating the left prefrontal cortex there was no effect on verbal fluency with a 1 mA current.6 ma and 1. while the reference electrode produces 18 µa/ *Skin preparation – abrasive gel – reduction of resistance and homogenization *As the increase in the density of the electric current provokes an increase in the cutaneous feeling of pain and affects different neuronal populations (due to a higher penetration of the effective electric field). One depression study using anodal stimulation at F3 noted alleviated depression using 1 ma into a 35 cm2 electrode (28 µa/cm2). the current rose to 0. et al.3 ma (current density of 15 ua/cm2). et al.. Iyer.5 cm) tap-water wet sponge anode at F3 and a 2”x 4” (5. When we increased the anode at F3 to 2”x 4”. the current flow was 0. We did some testing with a 9-volt battery supplying a 1 ¾” by 1 ¾” (4. and therefore not effective. in general. the active electrode delivers 50 µa/cm2. 2007) also used 2 ma.6 ma.000 ohms. it is recommended.1 x 5. Two depression studies by Boggio. the connection becomes poor and jumps to 20.

that will facilitate focal. is currently being developed for the restoration of CNS and PNS function. The advantage of HD-tDCS over conventional big pad tDCS involves using an array of <12 mm diameter stimulation electrodes. safe and customized neuromodulation of the brain function. High-Definition tDCS (HD-tDCS). .duration of stimulation and not in the current density to prolong the effects of TDCS (HD-tDCS) A new technology.

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*recent data demonstrate that tDCS can modulate the function of the spinal cord and of the cerebellum .

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